Effect of Modified Constraint-Induced Movement Therapy on Upper Limb Function in Children with Hemiplegic Cerebral Palsy

Abstract

To assess the effectiveness of modified constraint-induced movement therapy (mCIMT) in improving upper limb function and grip strength in children with hemiplegic cerebral palsy (CP).

A comprehensive search was conducted from inception to August 2024. Eligibility criteria were studies evaluating the effectiveness of mCIMT on upper limb function in children with hemiplegic CP aged over 2 years. The following data was extracted from each study: participant characteristics, intervention, outcome measures, follow-up, and key findings. The risk of bias and the quality of the evidence were evaluated using the PEDro scale and the grading of recommendations assessment development and evaluation (GRADE), respectively. A meta-analysis using a random-effect model was performed, and standardized mean difference (SMD) with a 95% confidence interval (CI) was estimated for upper limb function and grip strength.

A total of 25 studies (1,115 children) were included. PEDro scale revealed 12 good-quality studies, 8 fair-quality studies, and 5 poor-quality studies. The currently available evidence showed a significant large effect of mCIMT in improving upper limb function (SMD: 1.14 [95% CI: 0.46–1.83]; p = 0.001; 12 studies; 454 children; very-low-quality evidence) and significant medium effect in improving grip strength (SMD: 0.63 [95% CI: 0.12–1.14]; p = 0.02; 3 studies; 92 children; low-quality evidence).

mCIMT could improve upper limb function and grip strength in children with hemiplegic CP. However, due to the low and very low quality of evidence, further high-quality trials are needed to confirm these effects.

PROSPERO registration number (CRD42023413525).

Keywords

modified constraint-induced movement therapy - mCIMT - upper limb - rehabilitation - hemiplegic cerebral palsy

Authors' Contribution

All authors contributed to the study conception and design and material preparation, data collection, and analysis and read and approved the final manuscript. The first draft of the manuscript was written by E.A.E.K. and N.A. and all authors commented on previous versions of the manuscript. E.A.E.K. had the idea for the article, reviewed the literature search and data analysis, and drafted and/or critically revised the work.

E.A.E.K.: Study conception and design, project administration and supervision, methodology (evaluate the methodological quality and quality of evidence), and writing (the first draft).

Nahla Almatrafi: Investigation (assessing the articles for relevance and reviewing the extracted data from articles), methodology (evaluating the methodological quality), and writing (revising and editing the first draft).

M.A.: Registration process on the PROSPERO, methodology (evaluate the methodological quality and quality of evidence), and formal analysis (meta-analysis software).

H.M.: Formal analysis (review the founded articles for eligibility and remove duplication by endnote), investigation (assessing the articles for relevance and reviewing the extracted data from articles), validation in the methodological quality (a third reviewer), and writing (revised and editing the first draft).

N.T. and Najwa Abuallam: Searching for the included articles using the keywords in different databases, methodology (data extraction for included articles), and methodology (data extraction for included articles).

Publication History

Received: 14 February 2025

Accepted: 14 May 2025

Accepted Manuscript online:
20 May 2025

Article published online:
04 June 2025

• References

• 1 Tseng SH, Lee JY, Chou YL, Sheu ML, Lee YW. Association between socioeconomic status and cerebral palsy. PLoS One 2018; 13 (01) e0191724
• 2 Blair E, Cans C, Sellier E. Epidemiology of the Cerebral Palsies, in Cerebral Palsy: A Multidisciplinary Approach, C.P. Panteliadis, Editor. 2018. Springer International Publishing: Cham; 19-28
• 3 Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil 2006; 28 (04) 183-191
• 4 Eliasson AC, Forssberg H, Hung YC, Gordon AM. Development of hand function and precision grip control in individuals with cerebral palsy: a 13-year follow-up study. Pediatrics 2006; 118 (04) e1226-e1236
• 5 Auld ML, Boyd R, Moseley GL, Ware R, Johnston LM. Tactile function in children with unilateral cerebral palsy compared to typically developing children. Disabil Rehabil 2012; 34 (17) 1488-1494
• 6 Tonmukayakul U, Imms C, Mihalopoulos C. et al. Health-related quality of life and upper-limb impairment in children with cerebral palsy: developing a mapping algorithm. Dev Med Child Neurol 2020; 62 (07) 854-860
• 7 Van Zelst BR, Miller MD, Russo R, Murchland S, Crotty M. Activities of daily living in children with hemiplegic cerebral palsy: a cross-sectional evaluation using the assessment of motor and process skills. Dev Med Child Neurol 2006; 48 (09) 723-727
• 8 Klingels K, Jaspers E, Van de Winckel A, De Cock P, Molenaers G, Feys H. A systematic review of arm activity measures for children with hemiplegic cerebral palsy. Clin Rehabil 2010; 24 (10) 887-900
• 9 Deluca SC, Echols K, Law CR, Ramey SL. Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006; 21 (11) 931-938
• 10 Sakzewski L, Ziviani J, Boyd R. The relationship between unimanual capacity and bimanual performance in children with congenital hemiplegia. Dev Med Child Neurol 2010; 52 (09) 811-816
• 11 Rostami HR, Malamiri RA. Effect of treatment environment on modified constraint-induced movement therapy results in children with spastic hemiplegic cerebral palsy: a randomized controlled trial. Disabil Rehabil 2012; 34 (01) 40-44
• 12 Taub E, Crago JE, Burgio LD. et al. An operant approach to rehabilitation medicine: overcoming learned nonuse by shaping. J Exp Anal Behav 1994; 61 (02) 281-293
• 13 Crago JE, Uswatte G. Constraint-induced movement therapy: a new approach to treatment in physical rehabilitation. Rehabil Psychol 1998; 43 (02) 152-170
• 14 Taub E, Griffin A, Nick J, Gammons K, Uswatte G, Law CR. Pediatric CI therapy for stroke-induced hemiparesis in young children. Dev Neurorehabil 2007; 10 (01) 3-18
• 15 Taub E, Morris DM. Constraint-induced movement therapy to enhance recovery after stroke. Curr Atheroscler Rep 2001; 3 (04) 279-286
• 16 Taub E, Miller NE, Novack TA. et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74 (04) 347-354
• 17 Eliasson AC, Krumlinde-Sundholm L, Gordon AM. et al; European network for Health Technology Assessment (EUnetHTA). Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol 2014; 56 (02) 125-137
• 18 Liepert J, Uhde I, Gräf S, Leidner O, Weiller C. Motor cortex plasticity during forced-use therapy in stroke patients: a preliminary study. J Neurol 2001; 248 (04) 315-321
• 19 Levy CE, Nichols DS, Schmalbrock PM, Keller P, Chakeres DW. Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. Am J Phys Med Rehabil 2001; 80 (01) 4-12
• 20 Sakzewski L, Carlon S, Shields N, Ziviani J, Ware RS, Boyd RN. Impact of intensive upper limb rehabilitation on quality of life: a randomized trial in children with unilateral cerebral palsy. Dev Med Child Neurol 2012; 54 (05) 415-423
• 21 Hoare BJ, Wallen MA, Thorley MN, Jackman ML, Carey LM, Imms C. Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst Rev 2019; 4 (04) CD004149
• 22 Sakzewski L, Ziviani J, Boyd RN. Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics 2014; 133 (01) e175-e204
• 23 Brady K, Garcia T. Constraint-induced movement therapy (CIMT): pediatric applications. Dev Disabil Res Rev 2009; 15 (02) 102-111
• 24 Page SJ, Levine P, Leonard A, Szaflarski JP, Kissela BM. Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial. Phys Ther 2008; 88 (03) 333-340
• 25 Page SJ, Sisto S, Levine P, McGrath RE. Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial. Arch Phys Med Rehabil 2004; 85 (01) 14-18
• 26 Page SJ, Levine P, Leonard AC. Modified constraint-induced therapy in acute stroke: a randomized controlled pilot study. Neurorehabil Neural Repair 2005; 19 (01) 27-32
• 27 Page SJ, Sisto SA, Levine P, Johnston MV, Hughes M. Modified constraint induced therapy: a randomized feasibility and efficacy study. J Rehabil Res Dev 2001; 38 (05) 583-590
• 28 Chiu HC, Ada L. Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review. J Physiother 2016; 62 (03) 130-137
• 29 Chen YP, Pope S, Tyler D, Warren GL. Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil 2014; 28 (10) 939-953
• 30 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 31 da Costa BR, Hilfiker R, Egger M. PEDro's bias: summary quality scores should not be used in meta-analysis. J Clin Epidemiol 2013; 66 (01) 75-77
• 32 Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83 (08) 713-721
• 33 Foley NC, Teasell RW, Bhogal SK, Speechley MR. Stroke rehabilitation evidence-based review: methodology. Top Stroke Rehabil 2003; 10 (01) 1-7
• 34 Atkins D, Best D, Briss PA. et al; GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328 (7454) 1490
• 35 Balshem H, Helfand M, Schünemann HJ. et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64 (04) 401-406
• 36 Guyatt G, Oxman AD, Akl EA. et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011; 64 (04) 383-394
• 37 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed.. Elsevier Science; 1988: 8-14
• 38 Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index?. Psychol Methods 2006; 11 (02) 193-206
• 39 Facchin P, Rosa-Rizzotto M, Visonà Dalla Pozza L. et al; GIPCI Study Group. Multisite trial comparing the efficacy of constraint-induced movement therapy with that of bimanual intensive training in children with hemiplegic cerebral palsy: postintervention results. Am J Phys Med Rehabil 2011; 90 (07) 539-553
• 40 Choudhary A, Gulati S, Kabra M. et al. Efficacy of modified constraint induced movement therapy in improving upper limb function in children with hemiplegic cerebral palsy: a randomized controlled trial. Brain Dev 2013; 35 (09) 870-876
• 41 Eugster-Buesch F, de Bruin ED, Boltshauser E. et al. Forced-use therapy for children with cerebral palsy in the community setting: a single-blinded randomized controlled pilot trial. J Pediatr Rehabil Med 2012; 5 (02) 65-74
• 42 Rostami HR, Arastoo AA, Nejad SJ, Mahany MK, Malamiri RA, Goharpey S. Effects of modified constraint-induced movement therapy in virtual environment on upper-limb function in children with spastic hemiparetic cerebral palsy: a randomised controlled trial. NeuroRehabilitation 2012; 31 (04) 357-365
• 43 Yu J, Kang H, Jung J. Effects of modified constraint-induced movement therapy on hand dexterity, grip strength and activities of daily living of children with cerebral palsy: a randomized control trial. J Phys Ther Sci 2012; 24 (10) 1029-1031
• 44 Nahar A, Dowarah BP, Devi SA, Dutta A. To study the effect of play therapy and child friendly constraint induced momement therapy to improve hand function in spastic hemiplegic cerebral palsy children: a comparative study. International Journal of Physiotherapy 2015; 2 (06) 1063-1069
• 45 Begum MR, Hossain M. Effectiveness of constraint induced movement therapy and bimanual therapy in children with hemiplegic cerebral palsy. Int J Sci Res 2019; 8 (07) 856-862
• 46 Palomo-Carrión R, Pinero-Pinto E, Ando-LaFuente S, Ferri-Morales A, Bravo-Esteban E, Romay-Barrero H. Unimanual intensive therapy with or without unaffected hand containment in children with hemiplegia. A randomized controlled pilot study. J Clin Med 2020; 9 (09) 2992
• 47 Bingol H, Kerem Gunel M, Alkan H. The efficacy of two models of intensive upper limb training on health-related quality of life in children with hemiplegic cerebral palsy mainstreamed in regular schools: a double-blinded, randomized controlled trial. Physiother Theory Pract 2023; 39 (01) 10-25
• 48 Fakharany MES, Olama KA, Madbouly ME, Omar TEI. Modified constraint-induced movement therapy versus mirror therapy on affected hand functions in hemiparetic children. Annals of Clinical and Analytical Medicine 2021; 12 (08) 924-928
• 49 Mohamed RA, Yousef AM, Radwan NL, Ibrahim MM. Efficacy of different approaches on quality of upper extremity function, dexterity and grip strength in hemiplegic children: a randomized controlled study. Eur Rev Med Pharmacol Sci 2021; 25 (17) 5412-5423
• 50 Ramey SL, DeLuca SC, Stevenson RD, Conaway M, Darragh AR, Lo W. CHAMP. Constraint-induced movement therapy for cerebral palsy: a randomized trial. Pediatrics 2021; 148 (05) e2020033878
• 51 Tezcan S, Çankaya T. The effect of modified constraint-induced movement therapy in children with hemiparetic cerebral palsy. Consecutive or intermittent days?. Disabil Rehabil 2022; 44 (24) 7500-7507
• 52 Bingöl H, Günel MK. Comparing the effects of modified constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy mainstreamed in regular school: a randomized controlled study. Arch Pediatr 2022; 29 (02) 105-115
• 53 Harini K, Raj G, Dhasaradharaman K, Robert F, Thenmozhi MP. A comparative study of play therapy and child friendly constraint induced movement therapy in cerebral palsy. Int J Health Sci Res 2022; 12 (07) 48-50
• 54 Babu JH, Srinivas MR, Kowshik Sai PD. Effectiveness of modified constraint–induced movement therapy compared to hand arm bimanual intensive therapy on quality of upper extremity function in hemiplegic cerebral palsy children – an experimental study. Neuroquantology 2023; 21 (01) 888-925
• 55 Bhargavi I, Prakash Pappala K, Apparao P. Effectiveness of constraint induced movement therapy versus bimanual training in children with unilateral cerebral palsy. Int J Health Sci Res 2023; 13 (04) 106-117
• 56 Liang KJ, Chen HL, Huang CW, Wang TN. Efficacy of constraint-induced movement therapy versus bimanual intensive training on motor and psychosocial outcomes in children with unilateral cerebral palsy: a randomized trial. Am J Occup Ther 2023; 77 (04) 7704205030
• 57 Wang TN, Liang KJ, Liu YC, Shieh JY, Chen HL. Effects of intensive versus distributed constraint-induced movement therapy for children with unilateral cerebral palsy: a quasi-randomized trial. Neurorehabil Neural Repair 2023; 37 (2-3): 109-118
• 58 Abdul-Rahman RS, Radwan NL, El-Nassag BA, Amin WM, Ali MS. Modified-constraint movement induced therapy versus neuro-developmental therapy on reaching capacity in children with hemiplegic cerebral palsy. Physiother Res Int 2024; 29 (01) e2069
• 59 Vaghela V, Parmar D. The effects of MCIMT versus MT in young children with spastic hemiplegic CP to improve hand function and strength of the paretic arm. Int J Sci Res 2015; 4: 4-438
• 60 Dong VA, Fong KN, Chen YF, Tseng SS, Wong LM. ‘Remind-to-move’ treatment versus constraint-induced movement therapy for children with hemiplegic cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 2017; 59 (02) 160-167
• 61 Bansal A, Diwan S. Effect of modified constraint induced movement therapy and hand arm bimanual intensive training on upper extremity skills and functional performance in children with spastic hemiplegic cerebral palsy. Int J Health Sci Res 2021; 11 (02) 32-43
• 62 Ashok H, Multani KS, Ahmed VNA, Nair LDV. Clinical and parental perceptions on functional improvement with constraint induced movement therapy vs bimanual therapy in hemiplegic cerebral palsy. Educational Administration: Theory and Practice 2024; 30 (05) 2296-2304
• 63 Jain T, Bisen R, Ranade P. Effectiveness of modified constraint-induced movement therapy compared to hand-arm bimanual intensive therapy on quality of upper extremity function in hemiplegic cerebral palsy children - an experimental study: effectiveness of modified CIMT compared to habit on quality of upper extremity function in hemiplegic cerebral palsy children. Natl J Integr Res Med 2021; 12 (02) 45-50
• 64 Dekkers KJ, Rameckers EA, Smeets RJ, Janssen-Potten YJ. Upper extremity strength measurement for children with cerebral palsy: a systematic review of available instruments. Phys Ther 2014; 94 (05) 609-622
• 65 Arnould C, Bleyenheuft Y, Thonnard JL. Hand functioning in children with cerebral palsy. Front Neurol 2014; 5: 48
• 66 Hoare B, Imms C, Randall M, Carey L. Linking cerebral palsy upper limb measures to the International Classification of Functioning, Disability and Health. J Rehabil Med 2011; 43 (11) 987-996
• 67 Gilmore R, Sakzewski L, Boyd R. Upper limb activity measures for 5- to 16-year-old children with congenital hemiplegia: a systematic review. Dev Med Child Neurol 2010; 52 (01) 14-21
• 68 Hoare BJ, Wasiak J, Imms C, Carey L. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. Cochrane Database Syst Rev 2007; 2 (02) CD004149
• 69 International classification of functioning, disability and health: children and youth version: ICF-CY. 2007. World Health Organization; 2007: 17-20
• 70 Harpster K. et al. Evidence-Based Care Guideline for Pediatric Constraint Induced Movement Therapy. Cincinnati Children's Hospital Medical Center; 2014
• 71 Krumlinde-Sundholm L, Eliasson A-C. Development of the assisting hand assessment: a rasch-built measure intended for children with unilateral upper limb impairments. Scand J Occup Ther 2003; 10 (01) 16-26
• 72 Sutcliffe TL, Logan WJ, Fehlings DL. Pediatric constraint-induced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging. J Child Neurol 2009; 24 (10) 1230-1235
• 73 Juenger H, Linder-Lucht M, Walther M, Berweck S, Mall V, Staudt M. Cortical neuromodulation by constraint-induced movement therapy in congenital hemiparesis: an FMRI study. Neuropediatrics 2007; 38 (03) 130-136
• 74 Manning KY, Fehlings D, Mesterman R. et al. Resting state and diffusion neuroimaging predictors of clinical improvements following constraint-induced movement therapy in children with hemiplegic cerebral palsy. J Child Neurol 2015; 30 (11) 1507-1514
• 75 Sterling C, Taub E, Davis D. et al. Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy. Pediatrics 2013; 131 (05) e1664-e1669
• 76 Friel KM, Ferre CL, Brandao M. et al. Improvements in upper extremity function following intensive training are independent of corticospinal tract organization in children with unilateral spastic cerebral palsy: a clinical randomized trial. Front Neurol 2021; 12: 660780
• 77 Kuhnke N, Juenger H, Walther M, Berweck S, Mall V, Staudt M. Do patients with congenital hemiparesis and ipsilateral corticospinal projections respond differently to constraint-induced movement therapy?. Dev Med Child Neurol 2008; 50 (12) 898-903
• 78 Eliasson AC, Sjöstrand L, Ek L, Krumlinde-Sundholm L, Tedroff K. Efficacy of baby-CIMT: study protocol for a randomised controlled trial on infants below age 12 months, with clinical signs of unilateral CP. BMC Pediatr 2014; 14: 141
• 79 Klepper SE, Clayton Krasinski D, Gilb MC, Khalil N. Comparing unimanual and bimanual training in upper extremity function in children with unilateral cerebral palsy. Pediatr Phys Ther 2017; 29 (04) 288-306
• 80 Merino-Andrés J, López-Muñoz P, Carrión RP, Martín-Casas P, Ruiz-Becerro I, Hidalgo-Robles Á. Is more always better? Effectiveness of constraint-induced movement therapy in children with high-risk or unilateral cerebral palsy (0-6 years): systematic review and meta-analysis. Child Care Health Dev 2024; 50 (03) e13262
• 81 Jackman M, Lannin N, Galea C, Sakzewski L, Miller L, Novak I. What is the threshold dose of upper limb training for children with cerebral palsy to improve function? A systematic review. Aust Occup Ther J 2020; 67 (03) 269-280
• 82 Brooks M. et al. Updated Systematic Review: Effectiveness of CIMT and mCIMT in Patients With Upper-Extremity Dysfunction After Stroke 2023. University of Alabama at Birmingham;
• 83 Page SJ, Levine P, Sisto S, Bond Q, Johnston MV. Stroke patients' and therapists' opinions of constraint-induced movement therapy. Clin Rehabil 2002; 16 (01) 55-60
• 84 Palomo-Carrión R, Romay-Barrero H, Romero-Galisteo RP, Pinero-Pinto E, López-Muñoz P, Martínez-Galán I. Modified constraint-induced movement therapy at home-is it possible? Families and children's experience. Children (Basel) 2020; 7 (11) 248
• 85 Faccioli S, Pagliano E, Ferrari A. et al. Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: a systematic review. Front Neurol 2023; 14: 1171224
• 86 Novak I, McIntyre S, Morgan C. et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013; 55 (10) 885-910
• 87 Novak I, Morgan C, Fahey M. et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Curr Neurol Neurosci Rep 2020; 20 (02) 3
• 88 Tervahauta MH, Girolami GL, Øberg GK. Efficacy of constraint-induced movement therapy compared with bimanual intensive training in children with unilateral cerebral palsy: a systematic review. Clin Rehabil 2017; 31 (11) 1445-1456
• 89 Dong VA, Tung IH, Siu HW, Fong KN. Studies comparing the efficacy of constraint-induced movement therapy and bimanual training in children with unilateral cerebral palsy: a systematic review. Dev Neurorehabil 2013; 16 (02) 133-143
• 90 Hoare B, Greaves S. Unimanual versus bimanual therapy in children with unilateral cerebral palsy: same, same, but different. J Pediatr Rehabil Med 2017; 10 (01) 47-59
• 91 Hoffmann TC, Glasziou PP, Boutron I. et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014; 348: g1687